Today, we have options for treatment. Endermologie, a non-invasive treatment was developed in France in the seventies. It basically lifted the fatty area with suction, and rolled the tissue between 2 rollers. No fat was actually removed, but it did improve lymphatic drainage and gave the appearance of being more smooth for a while. Treatments were usually done once or twice a week for several weeks. It was then recommended to do maintenance treatments.

Since then, many versions of this system have been reproduced and modified. Other treatments have been tried such as intensed pulsed light, radiofrequency, ultrasound treatment, and infrared light with limited success.

In 2012, the FDA approved a minimally invasive laser treatment, Cellulaze, for the treatment of cellulite. The advantage of this procedure is that it is usually done one time, usually under local anesthesia, and is very safe.

Through a tiny incision, a small laser tube is inserted under the skin to burn the fibrous bands between the skin and fat, and melt the fat. With this treatment, we see permanent reduction of the fibrous tissue, shrinkage of the fat, and smoothing of the skin.  Altogether, the healing time is 6 months as the skin slowly smooths and improves. Studies have shown that the skin increases in thickness and elasticity. This treatment is safe and successful in treating cellulite.

In recent years, a specific gene structure has been identified that is also associated with a high frequency of breast and ovarian cancer:  these genes are called BRAC-1 and BRAC-2 (4,5) .   A simple blood test can be used to determine the presence of these genes, and close consultation with your physician can determine if a preventive mastectomy is appropriate for you.  The identification of this gene together with a positive family history of breast cancer place a woman at very high risk (up to 80-90%) of developing breast cancer.  Some women are not willing to have a “wait and see” approach to their risk and choose a more active option by removing their breast tissue before any disease is detected with the surgical procedure of preventive mastectomy (6).  Other non-surgical alternatives like tamoxifen or other hormonal drugs are not as effective in preventing breast cancer as is the surgical option of a preventive mastectomy.

Preventive mastectomy is a very different procedure from the treatment performed for patients with breast cancer.  The goal of a preventive mastectomy is the removal of the majority (95% or more) of the breast tissue mound and the majority of the breast tissue in the area of the areola and the armpit (axillary tail).  Since preventive mastectomy is not performed for the treatment of breast cancer, there are no concerns of disease in the lymph nodes and no need for the removal of all breast tissue in the area.    Therefore, the preservation of the entire breast skin envelope is possible with a great advantage in re-creating a full, supple and well- shaped breast.  It is remotely possible that some breast tissue may be left behind after a preventive mastectomy, and later be the source of breast cancer, but the likelihood of this event is very low.

Breast reconstruction is an integral part of a preventive mastectomy. Usually, a nipple sparing mastectomy is performed since no disease is expected in the mild ducts.  Nipple sparing mastectomy consists of removing the breast tissue from under the breast skin while preserving the skin enveloping the breast tissue, as well as the skin and structure of the nipple.  This option gives a vastly superior reconstruction outcome because a more natural appearance of the breast is ensured by the presence of the natural nipple.  In most cases, a small incision in the lower aspect of the areola is sufficient to perform the entire preventive mastectomy and reconstruction.  Immediate reconstruction of the breast mound with a breast implant is the most common technique used, followed by a combination of implant and muscle and fat tissue or tissue alone.  Sometimes, additional procedures are performed to decrease the risk of complications; these procedures include nipple delay (7) (a small procedure to partially separate the nipple tissue from the breast tissue below it and increase its blood flow – this procedure is done a few weeks before the mastectomy) and tissue expander placement. Some surgeons advocate the use of additional materials like Alloderm® or Strattice® to increase reliability of the reconstruction.

In summary, preventive mastectomy can be an excellent option for women with high risk of breast cancer who do not want to undergo prolonged monitoring.  Immediate breast reconstruction should be considered integral part of a preventive mastectomy.  Nipple sparing mastectomy and implant reconstruction can produce a natural, supple breast with shortened recovery time and excellent aesthetic outcomes.

References:

1.  http://www.mayoclinic.com/health/prophylactic-mastectomy/WO00060
2. http://www.cancer.gov/cancertopics/factsheet/Therapy/preventive-mastectomy
3. http://www.ncbi.nlm.nih.gov/pubmed/23336662
4. http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA
5. PDQ® Cancer Information Summary. National Cancer Institute; Bethesda, MD. Genetics of Breast and Ovarian Cancer (PDQ®) – Health Professional. Date last modified 04/24/2009. Available at: http://www.cancer.gov/cancertopics/pdq/genetics/breast-and-ovarian/healthprofessional
6. . Angelina Jolie (05/14/2013). “My Medical Choice”. New York Times. Retrieved 05/15/2013.
7. Jensen, J. A.; Lin, J. H.; Kapoor, N.; Giuliano, A. E. (2012). “Surgical Delay of the Nipple–Areolar Complex: A Powerful Technique to Maximize Nipple Viability Following Nipple-Sparing Mastectomy”. Annals of Surgical Oncology 19 (10): 3171–3176. doi:10.1245/s10434-012-2528-7http://www.ncbi.nlm.nih.gov/pubmed/22829005

This particular procedure was performed with a combination of periareolar (around the nipple) incision and inframammary (breast fold) incision.

To avoid the vertical scar from the areola to the breast fold this technique can be used with successful outcomes and reduced scars.